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Patient-Centered Medical Home and Quality Measurement in Small Practices

Jason J. Wang, PhD; Chloe H. Winther, BA; Jisung Cha, PhD; Colleen M. McCullough, MPA; Amanda S. Parsons, MD, MBA; Jesse Singer, DO, MPH; and Sarah C. Shih, MPH
Small practices with NCQA patient-centered medical home recognition perform better on quality measures, especially those related to chronic conditions.
Out of 776 practices enrolled in PCIP as of July 2012, 349 were live on their system prior to October 2009. Of those, 150 practices met the selection criteria for inclusion in this analysis. Of the 150 included practices, 39.3% have achieved PCMH recognition from NCQA (Figure 1A), including 1 Level 2 and 12 Level 3 practices. The earliest practice to achieve PCMH recognition did so in February 2010, and the latest practice became PCMH-recognized in February 2012; half of practices gained recognition by December 2010.

PCMH-recognized and nonrecognized practices did not statistically differ at baseline in months using EHR, total encounters, number of clinicians, clinician FTE, or insurance type. PCMH-recognized practices had a slightly, though statistically significant, larger proportion of patients with hypertension (Table 2). A comparison of performance between practices by recognition level yielded no significant differences on any measure (data not shown).

At baseline, PCMH-recognized practices performed significantly better than nonrecognized practices on 5 of the 7 quality measures (Table 1). There was no difference in performance at baseline between PCMH-recognized and nonrecognized practices for the 2 blood pressure control measures. At the later time point (October 2011), PCMH-recognized practices outperformed nonrecognized practices on A1C testing, BMI recorded, blood pressure control in patients with both hypertension and diabetes, smoking status recorded, and smoking cessation intervention measures. There was no significant difference in performance between the practice groups on antithrombotic therapy and blood pressure control in patients with hypertension only.

Overall, both groups of practices improved on every measure over the 2-year period (Table 1). For 6 of the 7 measures, time using the EHR was a significant predictor of improvement (Table 3). For both of the blood pressure control measures, the interaction term was significant with an OR greater than 1, indicating that PCMH-recognized practices improved at a faster rate than nonrecognized practices. For the A1C testing measure and the BMI recorded measure, the interaction term was significant with an OR less than 1, suggesting that nonrecognized practices improved at a faster rate than PCMH-recognized practices. By the end of the study period, PCMH-recognized practices, on average, had received 4 more visits than nonrecognized practices with PCIP QI staff (Figure 1B).

DISCUSSION

Practices in both the PCMH-recognized and nonrecognized groups significantly improved performance on key clinical quality measures over the 2-year study period. At both the baseline and later time points, practices that had achieved PCMH recognition consistently performed better on process measures, including measures referring to in-office screenings or documentation proficiency, than practices that had not achieved PCMH recognition. PCMH-recognized practices performed about the same as nonrecognized practices at baseline on the blood pressure control measures in both diabetic and nondiabetic patients.

Time using the EHR was the most significant predictor of improvement on all quality measures, and the average time using the EHR was roughly the same for both groups of practices. Although both groups of practices improved on all measures over time, for some measures, PCMH recognition was associated with even greater improvement. PCMH-recognized practices improved at a faster rate than nonrecognized practices on both of the blood pressure control measures over the 2-year period, suggesting that PCMH recognition may have a positive effect on the quality of care for patients with multiple chronic conditions. Given that improved performance on these measures requires not only clinician intervention (eg, medication order) but also patient engagement (eg, medication compliance, lifestyle changes), it may be that practices that achieve recognition as a PCMH have learned to provide an enhanced level of care, enabling them to do better on these types of measures. There are different pathways of implementing the PCMH model and practices emphasize different components depending on their circumstances 20; however, PCMH pilots across the country have shown a similar correlation between component processes of the PCMH model and improvements in quality of care for patients with multiple morbidities.10,22 Additionally, practice facilitator programs have been shown to have a positive impact on practice transformation; the PCIP QI curriculum may have had similar effects on the adoption of new processes or guidelines.23

For other measures, PCMH recognition was not associated with a greater rate of improvement. Both groups improved at approximately the same rate on antithrombotic therapy and the 2 smoking measures, although a large gap remained in performance between PCMH-recognized and nonrecognized practices. Nonrecognized practices improved at a higher rate on BMI recorded and A1C testing. For both of these measures, nonrecognized practices performed significantly below PCMH-recognized practices at baseline, and our results indicated that over time, nonrecognized practices were able to reduce the initial gap in performance. Also worth noting is that the baseline rate of BMI recorded was quite high for PCMH-recognized practices (86%), and these practices may have reached a performance ceiling over the course of the study, whereas nonrecognized practices had more room to improve, leaving an opportunity to close the performance gap.

As part of the PCIP program, all practices were offered extensive on-site technical support. At baseline, there was no difference in the number of QI visits provided by PCIP staff to the 2 groups of practices, but by the later time period, the PCMH-recognized group received an average of 4 additional QI visits compared with nonrecognized practices. This may be due in part to the time needed to provide assistance with the NCQA application; we were not able to assess the reasons for visits. Practices were given the option for additional QI visits and could receive them upon request. Those that did request additional QI visits were committed to giving time and staffing, including closing the practice or meeting during off hours, which may have been more difficult for some practices than for others. There may have been different levels of motivation as well as resource availability for practices that sought additional visits.

Resource barriers to PCMH transformation have been well described12 and many have noted that small practices struggle to secure the resources to support their transformative efforts.11 While support from PCIP QI staff may alleviate some of the barriers for small practices to achieve or maintain PCMH-recognition, PCMH-recognized practices invested significant time and resources of their own in the transformation and application process. For some practices, achievement of PCMH recognition would not be possible without PCIP assistance. In addition to challenges posed by resource-strapped settings, QI staff observed that small practices may have difficulty interpreting or adapting key PCMH concepts such as care coordination and team-based care in smaller practices with fewer staff.24 Evidence has shown that shared technical assistance, like that provided by PCIP, can be a key element in enabling small practices to successfully implement these concepts.25

These results demonstrate that both groups of participating practices have an ongoing commitment to quality that requires considerable effort and resources. Furthermore, despite all of the challenges they face, nearly 40% of small practices are able to operationalize the core components of the PCMH model, make meaningful changes to their practice, and improve quality with the aid of PCIP QI staff support. In order to expand these positive results, it is important for payers and policy makers to identify opportunities to provide support for small practices in implementing PCMH processes.

Limitations and Next Steps

This analysis only covered a 2-year period. We do not know whether the difference in performance among PCMH-recognized and nonrecognized practices can be sustained in the longer-term, or whether the differences would shrink or grow over time. Additionally, recent policy changes, such as the January 2013 expiration of New York State Medicaid incentive payments for PCMH Level 1 practices, may have an impact on recognition and performance trends. In addition, practices may continue to transform their office workflows and care processes—for instance, practices that have not yet achieved PCMH recognition from the NCQA may do so in the future, and those that are already PCMH-recognized may in the future achieve recognition at a higher level or reapply for recognition under the tougher 2011 standards. While we know that improvements may be a result of coding and documentation, we believe this is a limitation for measures where coding can impact measurement, such as smoking status recorded and smoking cessation intervention. Quality measures that rely on vitals or lab results, such as BMI, blood pressure, and A1C, are less prone to variations in documentation practices and likely reflect an improvement in the quality of care in addition to coding.26

The goal of this paper was to highlight a difference in performance rates among practices that have and have not achieved PCMH recognition, but we cannot yet speak to what is causing the difference. Using the data currently available, the PCMH-recognized and nonrecognized practices appear very similar in practice characteristics with the exception of racial demographics and the number of patients with hypertension. However, the baseline performance differences on most of these measures suggest that there may be other factors associated with these practices that may contribute to these differences that we could not detect with the data available to us.

Recent research has shown that the practice characteristics measured here may be less important to the key PCMH element of “team” than engaged leadership and organizational culture.27,28 Although all PCIP practices were offered the same quality improvement opportunities, given the differences in practice performance at baseline, it is possible that practices that were more organized, had stronger management, and provided higher quality care were more likely to elect to become PCMH-recognized.29 For this reason there may be non-random selection in the recognized group. Other differences could include similarly difficult-todefine concepts, such as motivation. As part of the evaluation of the National Demonstration Project for PCMH, researchers identified 1 such concept—an element of “adaptive reserve” which they were able to scale and quantify. 7 This concept covers a range of practice characteristics, including leadership and team relationships, which could contribute to a practice’s capacity to absorb change and lead to successful transformation and better quality outcomes. Further research is needed to delve into other potential factors that can sustain practice improvement, especially in small practices serving economically depressed populations. In particular, further research is needed to better define these concepts in the context of small practices.

 
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